All are equal, but some are more equal than others: social determinants of leisure time physical activity through the lens of intersectionality.

BACKGROUND: To date, no research has investigated social determinants of leisure time physical activity through the lens of intersectionality in a low- and middle-income country. Therefore, the aim of this study was to explore the intersectionality in leisure time physical activity in a nationwide sample of Brazilian adults. METHODS: Data from the Brazilian National Health Survey conducted in 2013 were analysed (N = 58,429). Prevalence of sufficient leisure time physical activity (150+ minutes per week in moderate-to-vigorous physical activity) was estimated according to gender, racial identity, education and income, and according to multiple combinations of these sociodemographic characteristics (i.e., multiple jeopardy index). RESULTS: The prevalence of sufficient leisure time physical activity was 22.9% (95%CI: 22.3 to 23.6). Overall, the prevalence of sufficient leisure time physical activity was highest among men, individuals with white skin colour, and among those in the highest group of education and income. Among men, white, with a university degree and in the highest quartile of income (3% of the population), the prevalence of sufficient leisure time physical activity was 48%. Among non-white women with low education and low income (8.1% of the population), the prevalence of sufficient leisure time physical activity was 9.8%. CONCLUSION: Informed by the theory of intersectionality, findings of this study have shown that intersections of gender, racial identity and socioeconomic position of the Brazilian society strongly influence leisure time physical activity at the individual level. Targeted interventions to increase leisure time physical activity should address the complexities of social status intersections.

The Global Burden of Disease Study Estimates of Brazil's Cervical Cancer Burden.

Background: Cervical cancer represents an important preventable cause of morbidity and mortality in developing countries such as Brazil. Investigating temporal evolution of a disease burden in the different realities of the country is essential for improving public policies. Objective: To describe the national and subnational burden of cervical cancer, based on the estimates of the 2017 Global Burden of Disease study. Methods: Descriptive study of premature mortality (years of life lost [YLL]) and burden of disease (disability-adjusted life years [DALYs]) associated with cervical cancer among Brazilian women aged 25-64 years, between 2000 and 2017. Findings: During the study period, age-standardized incidence decreased from 23.53 (22.79-24.26) to 18.39 (17.63-19.17) per 100,000 women, while mortality rates decreased from 11.3 (11.05-11.56) to 7.74 (7.49-8.02) per 100,000 women. These rates were about two to three times greater than equivalent rates in a developed country, such as England: 11.98 (11.45-12.55) to 10.37 (9.85-10.9), and 3.75 (3.68-3.84) to 2.82 (2.75-2.9) per 100,000 women, respectively. Poorer regions of Brazil had greater rates of the disease; for instance, Amapá State in the Northern Region had rates twice as high as the national rates during the same period. Cervical cancer was the leading cause of premature cancer-related mortality (YLL = 100.69, 91.48-110.61 per 100,000 women) among young women (25-29 years) in Brazil and eight federation units of all country regions except the Southeast in 2017. There was a decrease in the burden of cervical cancer in Brazil from 339.59 (330.82-348.83) DALYs per 100,000 women in 2000 to 238.99 (230.45-247.99) DALYs per 100,000 women in 2017. Conclusion: Although there has been a reduction in the burden of cervical cancer in Brazil, the rates remain high, mainly among young women. The persistence of inequalities between regions of Brazil suggests the importance of socioeconomic determinants in the burden for this cancer.

Social, Environmental and Behavioral Determinants of Asthma Symptoms in Brazilian Middle School Students-A National School Health Survey (Pense 2012).

Biological and psychosocial factors are recognized contributors to the worldwide burden of asthma. However, the relationship between psychosocial factors and asthma symptoms among students in low- and middle-income countries remains underexplored. We aimed to identify socioeconomic, environmental, psychosocial, family-related and lifestyle factors associated with the self-reporting of asthma symptoms in Brazilian adolescents. This is a cross-sectional study using data from the 2012 PeNSE survey (n = 109,104). We analyzed the following variables: socioeconomic conditions, demographic characteristics, lifestyle, family context and dynamics, psychosocial indicators, smoking, and exposure to violence. Our outcome variable was the self-report of asthma symptoms in the past 12 months. The prevalence of wheezing was 22.7% (21.5⁻23.9). After adjusting for sex, age and the variables from higher hierarchical levels, exposure to violence (feeling unsafe at school, being frequently bullied, being exposed to fights with firearms) and physical aggression by an adult in the family were the environmental factors that showed the strongest associations with self-reporting of asthma symptoms. For psychosocial indicators of mental health and social integration, feelings of loneliness and sleeping problems were the strongest factors, and among individual behavioral factors, the largest associations were found for tobacco consumption. Our findings were consistent with previous studies, showing an association between self-reported asthma symptoms and socio-economic status, family context and dynamics, psychosocial indicators of mental health, exposure to violence and social integration, as well as a sedentary lifestyle and tobacco use.

Effectiveness of a scaled up physical activity intervention in Brazil: A natural experiment.

Physical inactivity causes 5.3 million deaths annually worldwide. We evaluated the impact on population leisure-time physical activity (LTPA) of scaling up an intervention in Brazil, Academia das Cidades program (AC-P). AC-P is a health promotion program classified as physical activity classes in community settings which started in the state of Pernambuco state in 2008. We surveyed households from 80 cities of Pernambuco state in 2011, 2012 and 2013, using monitoring data to classify city-level exposure to AC-P. We targeted 2370 individuals in 2011; 3824 individuals in 2012; and 3835 individuals in 2013. We measured participation in AC-P and whether respondents had seen an AC-P activity or heard about AC-P. We measured LTPA using the International Physical Activity Questionnaire. We estimated the odds of reaching recommended LTPA by levels of exposure to the three AC-P measures. For women, the odds of reaching recommended LTPA were 1.10 for those living in cities with AC-P activity for less than three years, and 1.46 for those living in cities with AC-P activity for more than three years compared to those living in cities that had not adopted AC-P. The odds of reaching recommended LTPA increased with AC-P participation and knowledge about AC-P. AC-P exposure is associated with increased population LTPA. Extending AC-P to all cities could potentially impact non-communicable diseases in Brazil.

Socioeconomic inequalities in activities of daily living limitations and in the provision of informal and formal care for noninstitutionalized older Brazilians: National Health Survey, 2013.

BACKGROUND: This study assesses the association between socioeconomic factors and living arrangements with activity of daily living limitations (ADL) and the receipt of informal and formal care among non-institutionalized Brazilians aged ≥ 60 years. METHODS: Data come from a nationally representative survey (the Brazilian National Health Survey), conducted in 2013. Outcomes examined include the number of ADL tasks performed with limitations and number of tasks for which the individual received informal care (provided by unpaid relatives or friends), formal care, or no care. Key exposure variables were years of education and household assets. RESULTS: Functioning limitations were reported by 7,233 (30.1 %) of 23,815 survey participants. Of these, 5,978 reported needing help to perform at least one ADL task. There was a strong inverse gradient between physical functioning and both education and household assets that was independent of confounders. The provision of care showed an opposite trend, with the wealthiest being more likely to receive help for performing ADL tasks. The receipt of formal care was strongly correlated with highest education (Fully adjusted prevalence ratio [PR] = 1.64; 95 % CI 1.05, 2.58) and with the highest assets level (PR = 2.24; 95 % CI 1.38, 3.64). Living with someone else was associated with provision of care (formal or informal) for those at the lowest and intermediate educational and assets levels, but not for the wealthiest. CONCLUSION: Despite worse physical functioning, older Brazilians in worse socioeconomic conditions are much less likely to receive needed help in performing ADL tasks.

A priority health index identifies the top six priority risk and related factors for non-communicable diseases in Brazilian cities.

BACKGROUND: In Brazil, 72% of all deaths in 2007 were attributable to non-communicable diseases (NCD). We used a risk and related factor based index to prioritize NCD prevention programs in the combined 26 capital cities and the federal district (i.e., Brasilia) of Brazil. METHODS: We used 2006-2011 data (adults) from census and Brazil's surveillance of 12 NCD risk factors and 74 disease group mortality. The risk and related factors were: smoking, physical inactivity, overweight-obesity, low fruits and vegetables intake, binge drinking, insufficient Pap smear screening (women aged 25 to 59 years), insufficient mammography screening (women aged 50 to 69 years), insufficient blood pressure screening, insufficient blood glucose screening, diagnosis of hypercholesterolemia, diagnosis of hypertension and diagnosis of diabetes. We generated six indicators: intervention reduction of the risk factor prevalence, intervention cost per person, prevalence of risk factor, deaths attributable to risk factor, risk factor prevalence trend and ratio of risk factor prevalence between people with and without a high school education. We transformed risk and related factor indicators into priority scores to compute a priority health index (PHI). We implemented sensitivity analysis of PHI by computing it with slightly altered formulas and altering values of indicators under the assumption of bias in their estimation. We ranked risk factors based on PHI values. RESULTS: We found one intermediate (i.e., overweight-obesity) and six top risk and related factors priorities for NCD prevention in Brazil's large urban areas: diagnosed hypertension, physical inactivity, blood pressure screening, diagnosed hypercholesterolemia, smoking and binge drinking. CONCLUSION: Brazil has already prioritized the six top priorities (i.e., hypertension, physical inactivity, blood pressure screening, hypercholesterolemia, smoking and binge drinking) and one intermediate priority (i.e., overweight-obesity) for NCD prevention identified in this report. Because effective interventions to reduce disease burden associated with each of the six priority risk factors are available, strategies based on these interventions need to be sustained in order to reduce NCD burden in Brazil. PHI can be used to track NCD prevention and health promotion actions at the local and national level in Brazil and in countries with similar public health surveillance systems.

Promoting physical activity and quality of life in Vitoria, Brazil: evaluation of the Exercise Orientation Service (EOS) program.

BACKGROUND: The purpose of this study was to evaluate associations between exposure to the Exercise Orientation Service (EOS) program and physical activity (PA) and quality of life (QoL) in adults from Vitoria, Brazil. METHODS: A phone survey was conducted with 2023 randomly selected participants (≥ 18 years) to measure awareness about the program, participation in the program, PA levels, and QoL. The associations were tested using Poisson and Linear regression models. RESULTS: 31.5% reported awareness about the program, 1.5% reported current participation, and 5.8% reported previous participation. Participation was higher among women (2.1%), older subjects (2.8%), and those reporting morbidities (2.4%). Awareness was higher among middle-aged persons (36.0%) and highly educated participants (37.1%). Current participation (PR = 2.22; 95% CI = 1.65-2.99) and awareness (PR = 1.15; 95% CI = 1.02-1.30) were associated with leisure-time PA (LTPA). CONCLUSION: Exposure to the program was not associated with QoL but was consistently associated with sufficient levels of LTPA among adults from Vitoria, Brazil.

Country actions to meet UN commitments on non-communicable diseases: a stepwise approach.

Strong leadership from heads of state is needed to meet national commitments to the UN political declaration on non-communicable diseases (NCDs) and to achieve the goal of a 25% reduction in premature NCD mortality by 2025 (the 25 by 25 goal). A simple, phased, national response to the political declaration is suggested, with three key steps: planning, implementation, and accountability. Planning entails mobilisation of a multisectoral response to develop and support the national action plan, and to build human, financial, and regulatory capacity for change. Implementation of a few priority and feasible cost-effective interventions for the prevention and treatment of NCDs will achieve the 25 by 25 goal and will need only few additional financial resources. Accountability incorporates three dimensions: monitoring of progress, reviewing of progress, and appropriate responses to accelerate progress. A national NCD commission or equivalent, which is independent of government, is needed to ensure that all relevant stakeholders are held accountable for the UN commitments to NCDs.

Exposure to a community-wide physical activity promotion program and leisure-time physical activity in Aracaju, Brazil.

BACKGROUND: Evaluation studies of large scale physical activity promotion programs are rare in Latin America. The aim of the current study was to evaluate the association between various forms of exposure to Academia da Cidade (PAC), a professionally supervised intervention in Aracaju (Brazil), and leisure-time physical activity (LTPA). METHODS: A population-based study including 2267 adults was carried out. LTPA was assessed using the long version of the International Physical Activity Questionnaire, and a cut-off of 150 minutes per week was used in the analyses. RESULTS: In fully adjusted models, having ever heard about PAC was related to an odds of 1.8 (95% CI 1.4-2.2) for reaching the 150-minutes per week LTPA threshold. Equivalent odds ratios were 1.6 (95% CI 1.1-2.3) for having ever seen a PAC class, 14.3 (95% CI 12.3-16.4) for current and 4.0 (95% CI 1.4-11.3) for past PAC participation. CONCLUSION: Different sources of exposure to PAC were significantly associated with LTPA, which may suggest that professionally-supervised community classes offered for free may be a successful alternative for promoting physical activity in Brazil. If PAC happens to be expanded to other Brazilian areas, intervention studies may be carried out to evaluate its effectiveness.

Description of the countrywide physical activity network coordinated by the Brazilian Ministry of Health: 2005-2008.

BACKGROUND: Based on the Brazilian National Health Promotion Policy (PNPS), the Ministry of Health (MoH) started stimulating and funding physical activity interventions in 2005, leading to the establishment of a countrywide network. The aim of the present article is to geographically describe this network (2005-2008) and to present structure and process evaluation indicators of interventions funded in 2006 and 2007. METHODS: In 2005, the 27 state capitals received funding for carrying out physical activity-related interventions. From 2006 onwards, public calls for proposals were announced, and cities were selected through a competitive basis. Coordinators of interventions in cities who got funding in 2006 and 2007 answered to survey questions on structure and process aspects of the interventions. RESULTS: The network currently comprises 469 projects, out of which over 60% are carried out in small cities (<30,000 inhabitants). The most frequently used public spaces for the interventions are squares and indoor sports courts. The main physical activity-related topic of the PNPS prioritized in the projects is healthy diet. The main partnerships developed are between City's Health and Education Secretariats. CONCLUSION: Expanding the network to 1000 cities by 2010 and continuing the evaluation efforts are the next goals of the Brazilian MoH.